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Iowa Department of Human Services
Mental Health and Disability Services Redesign Progress Report
December 1, 2016
11/15/2016 Page 2
Table of Contents
Executive Summary. ....................................................................................................... 3
Progress of the Implementation of the Adult Mental Health and Disability Services
Redesign ......................................................................................................................... 5
MHDS System Review .................................................................................................... 9
Challenges to the MHDS System .................................................................................. 12
Recommendations ........................................................................................................ 16
Appendix A: HF2460 Division XIX Mental Health and Disability Services Redesign
Progress Report Sec. 89 Mental Health and Disability Services Redesign Progress
Report. .......................................................................................................................... 18
Appendix B: MHDS Regions Map ................................................................................. 19
Appendix C: Population Per MHDS Region. ................................................................. 20
Appendix D: Core Service Access Standards ............................................................... 21
Appendix E: Core Plus Services – 9/30/16 .................................................................... 24
Appendix F: Evidence Based Practices......................................................................... 25
Appendix G: Summary of Maximum County MHDS Levies ........................................... 26
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Executive Summary
The purpose of this report is to review and report progress on the implementation of the
adult mental health and disability services redesign and identify any challenges faced in
achieving the goals of the redesign as required by HF 2460 Section 89. (Appendix A)
HF 2460 directs the Department to review and report on the following:
Governance, management, and administration;
The implementation of best practices including evidence-based best practices;
The availability of, access to, and provision of initial core services and additional
core services to and for required core service populations and additional core
service populations; and
The financial stability and fiscal viability of the redesign.
Improving the MHDS system has been an on-going journey. The MHDS Redesign has
moved the MHDS system several positive steps in this journey. However, much has
occurred that was not envisioned when the Redesign legislation was passed that affects
the MHDS system as a whole. Therefore, this report takes the opportunity to review the
current environment in which the MHDS system operates, the challenges it is facing,
and describe the next steps the Department will take to further improve the public
MHDS system as a whole.
The Department based its findings and recommendations in this report on data and
information collected from the MHDS Regions for the MHDS Regional Dashboard;
Medicaid claims data; hospital inpatient psychiatric bed tracking system data; reports
from MHDS advocacy groups; discussions with the DHS Council, MHDS Regional Chief
Executive Officers, MHDS Commission, and Mental Health Planning Council;
experience at the Department’s facilities; and experience from monitoring individual
situations brought to the Department’s attention.
Key findings for MHDS Regions:
Fourteen (14) MHDS Regions (Appendix B) have been successfully established
with only a few concerns such as: a small number of MHDS Regions do not
maintain continuity of leadership because they annually rotate the chief executive
officer (CEO) among county staff, a few MHDS Regions do not combine county
funds for common use (i.e., pooling), and several MHDS Region service areas
include too few residents to operate effectively and efficiently.
MHDS Regions are generally providing core services that meet access standards
to the core populations. In a few instances some standards are not being met
and core services are not consistent in quality and quantity across the state.
(Appendix D)
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Some MHDS Regions are providing optional core plus services: comprehensive
crisis services, jail diversion, and civil commitment prescreening. These optional
services are a significant improvement, but, since these are not required
services, they are not consistently available statewide. (Appendix E)
Some progress is being made developing evidence based practices, but much
more progress is needed. (Appendix F)
Most MHDS Regions have sufficient MHDS levy authority and fund balances to
operate at current service levels for several years.
Some MHDS Regions report that current MHDS levy limits create the perception
that some counties are subsidizing others. This is reportedly causing friction
among some MHDS Region member counties and inhibits pooling of funds. If
the role and responsibility of the MHDS Region is further expanded as indicated
in the recommendations below, additional funding may be needed in the future.
(Appendix G)
The Department believes there is sufficient funding authority for MHDS Regions
and views the perceived friction as primarily a tax policy question.
Key Findings for the MHDS System
A small number of individuals (i.e., less than 1%) with a mental illness,
intellectual disability, or co-occurring substance use disorder that also have
severe multiple complex needs are underserved, precariously served, or served
in higher levels of care than they need. Inadequately serving these individuals
has led some to the misperception there is a crisis in the MHDS system. Instead,
what is needed are more intensive effective supports and treatment that meet the
needs of those most challenging to serve, including 24 hour 7 day a week
residential services.
The MHDS system lacks clarity regarding what entity or entities are responsible
and accountable for ensuring that individuals with the most severe mutliple
complex needs are effectively and efficiently served.
Most MHDS providers do not have the capacity or capability to effectively serve
individuals with severe multiple complex needs. This lack of capacity has led to
the misperception that more public inpatient psychiatric hospital, state resource
center, and psychiatric medical institution for children beds are needed. Instead
what is needed is a more complete and effective continuum of services to meet
individuals’ needs, especially those with the most severe and complex needs.
There is no point of responsibility and accountability for the provision of critical
non-clinical social services, such as housing and transportation, which are
necessary for individuals with a severe mental illness or an intellectual disability
to live successfully in the community.
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MHDS Regions and the Managed Care Organizations (MCOs) have not yet
worked collaboratively to achieve statewide outcomes and goals that will improve
the MHDS system. This lack of organized effort has led to the belief that the
MHDS system is broken. Instead what is needed is to coordinate the efforts of
the MHDS Regions and the MCOs.
Sufficient funding exists for the MHDS system to successfully address the most
significant MHDS issues by building a more effective and efficient continuum of
services that achieves better outcomes for the individuals that are served.
Recommendations:
To strengthen the effectiveness and efficiency of the MHDS Regions, the Department
recommends the following:
MHDS Regions should: have a minimum number of county residents in each
region, pool county funding, and maintain continuity in their leadership.
MHDS Regions and MCOs should identify funding for the provision of all Core
and Core Plus services to individuals with a mental illness or an intellectual
disability.
MHDS Regions should continue building the community service system by
planning for the provision of critical, non-clinical social services, such as, but not
limited to, housing and transportation.
The MHDS Regions’ responsibility and authority for effectively and efficiently
serving individuals that are the most difficult to serve should be clarified.
To address the most pressing statewide MHDS system and behavioral health need (i.e.,
a complete and effective array of supports, treatment and care for individuals that are
the most difficult to serve) the Department will:
Immediately convene a workgroup that includes MHDS Regions, MCOs, and
other key stakeholders to identify effective services for individuals with severe multiple complex needs and report recommendations for the provision of the identified services.
Progress of the Implementation of the Adult Mental Health and
Disability Services Redesign
Mental Health and Disability Services Regional Service System Governance,
Management, and Administration
Fourteen (14) MHDS Regions have been formed and are operating under the direction
of governing boards made up of county supervisors from the Regions’ member
counties. (Appendix B) The governing boards are responsible for the management of
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the MHDS Regions and the expenditure of the Regions’ funds. The MHDS Regions
have established local points of contact for services, and the MHDS Regions have also
formed advisory committees of advocates, consumers, family members, and providers
to advise the governing boards.
The following describes three areas in which Regions differ in their management and
administration.
Role of the Chief Executive Officer
Twelve (12) MHDS Regions operate with a single chief executive officer (CEO). Single
CEO models are where the CEO is selected by the governance board and does not
change from year to year. MHDS Redesign envisioned a single CEO model, but did not
require it to be used.
Two (2) MHDS Regions operate a multiple CEO model in which the CEO role may
rotate between various participating county staff, usually former central point of
coordination administrators. In this model county employed coordinators (points of
contact) operate in an autonomous fashion from the MHDS Region.
The MHDS Region CEO’s role is made more complicated because most of the staff that
support the work of the MHDS Region are employees of counties and not employees of
the Region. This makes directing their work and holding them accountable more
difficult.
Pooling Funds
Pooling of funds is when all counties in the MHDS Region place their funds into a single
account to be used to pay for services region wide. Pooling of funds allows the MHDS
Region to take a unified, system wide management approach to service development
and delivery. Ten (10) MHDS Regions pool their funds.
MHDS Redesign envisioned that MHDS Regions would pool their funding, but the final
legislation did not require pooling.
Three (3) MHDS Regions place some of their funds in a single account. Only
specifically identified services are funded with pooled funds while the remaining
services are funded from member county accounts. Often expenditures from the
account are monitored so that one county’s funds are not used for residents of another
county. This is referred to as “virtual pooling.”
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One (1) MHDS Region draws funds from member counties as the funds are needed to
serve individuals that are residents of that county. This model meets requirements, but
falls short of the more unified approaches of pooling or virtual pooling.
Failing to pool funds is a barrier to providing a unified regional service delivery system
and fails to take advantage of the efficiencies and economies of scale that pooling of
funds provides.
Various Sizes of MHDS Regions
MHDS Regions serve member counties with significantly different numbers of residents.
(Appendix C) The Department believes that regions serving smaller numbers of
residents cannot operate efficiently and effectively. The original MHDS Redesign
Regionalization Workgroup identified the minimum number of residents an MHDS
Region serves should be between 200,000 and 700,0001. The final MHDS Redesign
legislation required MHDS Regions to include at least three counties, but it did not
require a minimum number of residents be included in an MHDS Region. The
Department recognizes that a region may potentially be too large geographically to be
effectively managed. This too needs to be guarded against.
Availability of, Access to, and Provision of Initial Core Services for Required Core
Populations
Iowa Code section 331.397 and 441 IAC 25.2 require MHDS Regions to provide a set of defined core services to a defined group of Iowans. Required core services and the access standards are found in Appendix D. MHDS Regions must provide these services to adults with a mental illness or an intellectual disability. This is referred to as the “core population.” Appendix D also shows the extent to which MHDS Regions are providing access to required core services to the required core population as of September 30, 2016, as reported by the MHDS Region CEOs. While most MHDS Regions are providing core services that meet access standards, the quality and quantity of those services are uneven and vary depending on where the individual lives. Availability of, Access to, and Provision of Core Plus Services and Services to Core Plus Populations
MHDS Regions that are providing core services to the required core population and
have additional available funds may choose to expand to core plus services. Core plus
services include services defined in Iowa Code section 331.397, subsection 6.
1 Iowa Mental Health and Disability Services System Redesign Final Report dated December 9, 2011
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Appendix E provides an overview of core plus services being provided as of September
30, 2016.
MHDS Regions that are providing core services to the required core population and have additional available funds may choose to expand services to core plus populations. Examples of core plus populations include:
Individuals with developmental disabilities,
Individuals with a brain injury,
Children with a mental illness or intellectual disability.
Overall, with some isolated exceptions, MHDS Regions serve relatively few individuals
in the core plus populations.
Implementation of Best Practices Including Evidenced Based Practices Iowa Code Section 331.397 subsection 5, requires that MHDS Regions ensure access to providers of core services that demonstrate competencies in serving persons with co-occurring conditions, provide evidenced based practices, and trauma informed care. “Evidence based practices” (EBP) are practices that have consistent scientific evidence showing they improve individual outcomes. 441 IAC 25.4 requires that MHDS Regions develop access to specific EBPs listed in Appendix F. These EBPs have the advantage of having research based fidelity standards that more objectively demonstrate whether or not the EBP is being delivered. Appendix F shows where the MHDS Regions have identified that they have providers working to implement the identified EBPs. MHDS Regions need to make more progress in developing and implementing EBPs in Iowa.
Financial Stability and Viability
Iowa Code 331.424A provides guidance and limitations on how much each MHDS
Region member county is allowed to levy. Counties are limited in the amount of levy
that they can raise for MHDS. MHDS Redesign funding was based on “equalization.”
Equalization means that each county has available the same amount of funding per
resident of the county from either the MHDS levy or a combination of the MHDS levy
and state general fund to support the MHDS Region. Iowa Code 426B identifies the
statewide per capita expenditure target amount for regions to fund MHDS services as
$47.28 per capita. Counties that were authorized to levy more than $47.28 are required
to lower their levy to that amount. Counties that had limits below $47.28 per capita
were to receive additional state general funds identified in a yearly appropriation to
make up the difference between their maximum levy and the $47.28 per capita amount.
11/15/2016 Page 9
For SFY14 and SFY15 the state appropriated $30 million in funding to counties that had
levy limits below $47.28 to provide “equalized” funding to MHDS Regions. As a result of
added state funding in the early years and county levy authority, nearly all MHDS
Regions have accumulated sizable fund balances. The legislature did not authorize a
state general fund appropriation for equalization for SFY16 and SFY17.
The accumulation of fund balances have provided MHDS Regions sizable funds with
which to operate, though fund balances should be considered one time funds. The
Department has estimated that, assuming counties approve the current maximum
MHDS levy and cost of MHDS Region services increases at 3% a year, nearly all
MHDS Regions could operate without financial difficulty until SFY25. However,
counties are not approving the maximum MHDS levy. The current SFY17 amount
levied across all counties is $87.9 million compared to the current maximum allowed
total of $114.6 million. If this lower levy rate continues, MHDS Region fund balances
will be spent sooner than SFY25.
Last legislative session the MHDS Regions and the Iowa State Association of Counties
(ISAC) reported that the inequities resulting from the limits on the MHDS levies is
causing strain in MHDS Region member county relationships. Counties with higher
MHDS levy limits perceive they are subsidizing counties that have lower MHDS levy
limits. (Appendix G) This perceived inequity is causing friction within some MHDS
Region member counties. The MHDS Regions and ISAC asked the legislature to
address this inequity by granting the counties the authority to raise the MHDS levy to
address the current funding inequity among counties.
MHDS System Review
Current Context
When reviewing information for this report the Department concluded it would be most
helpful to provide a broader view of the MHDS system beyond the MHDS Regions.
Since MHDS Redesign was enacted in 2012 the following changes have occurred that
were not envisioned when MHDS Redesign was passed that have significantly affected
the MHDS system. Some of these changes are described below.
State Change Financing
Total state and county spending for mental health and disability services is expected to
be about $2 billion for SFY13 through SFY17. About $1.5 billion of this amount is state
general funds. About $1.4 billion of the general funds were primarily used for the non-
federal share of Medicaid for mental health and disability services that resulted when
11/15/2016 Page 10
the state took over the financial responsibility for the non-federal share of Medicaid from
the counties and the MHDS Regions.
Medicaid Expansion
Beginning January 2014, the Iowa Health and Wellness Plan (IHAWP) expanded
comprehensive health care coverage to about 145,000 Iowans. This expansion
primarily benefited single adult low income males and is of particular assistance for
those needing behavioral health services. In addition, some of these newly covered
individuals that have a serious mental health or disability condition can now be eligible
for the more comprehensive Medicaid program coverage.2 As of January 2016 IHAWP
was expending about $67 million per year on behavioral health services (i.e., mental
health and substance use disorder services) and served about 35,360 individuals
whose services were previously the responsibility of the MHDS Regions. As a result,
the number of Iowans receiving services funded by the MHDS Regions has declined
significantly in recent years, as shown in the following chart:
Unduplicated Number of Individuals Whose Services were Funded by MHDS Regions
Population SFY13 SFY15
Individuals with Mental Illness 32,943 17,227
Individuals with Intellectual Disability 3,635 2,538
TOTAL 36,578 19,765
Managed Care Implementation
In April 2016 Iowa implemented the IA Health Link, a comprehensive managed care
program for Medicaid managed by three MCOs under contract with the Department.
Iowa’s transition to managed care marks a major change in the management approach
to Medicaid. The three MCOs are expected to be more than payers of service. They
are required to improve member outcomes through increased and improved care
management and coordination, and the use of health care transformation practices that
result in more effective and efficient service delivery. MCOs operate within highly
comprehensive contracts that include extensive Departmental oversight. This new
approach is expected to significantly improve the health and wellbeing of MCO
members including those with mental illness or disabilities.
Health Care Transformation
Health care management is moving beyond the principles of MHDS Redesign – regional
management, local service delivery, and statewide standards – to new health care
transformation practices with greater promise of progress and success. Health care
transformation is the trend to move away from the traditional patient/provider/payer
2 The process called being determined medically exempt provides more expansive regular Medicaid coverage for
individuals with the most severe disabilities.
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model to a model that uses proven practices to improve patient outcomes including:
population management, social determinants of health, and value based purchasing.
The MCOs are required to use value based purchasing and are being encouraged to
use the other practices to improve member outcomes and achieve greater efficiency.
MHDS Regions are not required to use these practices. This means providers must
operate in two different worlds: one world that is moving forward with payment for
outcomes and incentives for performance, and the other world that operates using
older, less efficient payment for volume of service. If MHDS Regions do not use these
new practices they will be left behind and they will not be equipped to operate in the
new, emerging managed health environment.
Program Initiatives
Iowa has adopted several key program initiatives designed to increase and improve
MHDS program policy approaches such as:
The Home and Community Based Services (HCBS) settings rules required by
the Centers for Medicare and Medicaid Services to ensure individuals are living
community integrated lives;
Increased reimbursement for supported employment to encourage individuals
with mental illness or other disabilities to gain and keep integrated employment;
Integrated Health Homes to improve care coordination for individuals with serious
mental illness and improve health care outcomes;
Systems of Care to improve the mental health and wellbeing of children with a
serious emotional disturbance and their families;
Certified Community Behavioral Health Clinics to develop community mental
health provider capacity to better serve individuals with a serious mental illness;
Hospital inpatient bed tracking system to improve the efficiency of locating
available inpatient psychiatric hospital beds for individuals that need them;
Autism Support Program to provide proven and effective services for children
with autism for families that cannot afford to pay for them;
In addition to these intiatives, the Children’s Mental Health and Wellbeing Workgroup is
implementing two projects, one on children’s crisis services and the other on learning
labs for children and family wellbeing. The workgroup is developing a proposal to
continue building a children’s system that will focus on prevention. This next step will
help design regional collaborative interagency approaches to prevention that will
improve child and family wellbeing.
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Perceptions
The MHDS service system is a developing system that has both strengths and
weaknesses. For example, due to the IHAWP and MHDS Regions, every low income
Iowan needing MHDS services has an entity responsible to pay for their needed
services. More low income Iowans than ever before are receiving publicly funded
mental health and developmental disability services.
However, a small number of individuals with severe and multiple complex needs are
inadequately served. Tragic events have occurred that could potentially have been
avoided with better and more comprehensive services.
Funds available for the MHDS Regions are substantial and can support expansion of
services for years into the future, but much of that funding is from one time fund
balances that are being slowly depleted and continuing to rely on fund balances is
unsustainable.
The number of staffed operating inpatient psychiatric hospital beds in Iowa has grown
from 721 beds in January 2016 to 744 beds in August 2016. Iowa has one of the few
inpatient psychiatric hospital bed tracking systems in the nation. Over the last 12
months, the psychiatric hospitals reported an average of 72 vacant beds per day
through the bed tracking system. Yet Iowa has fewer state mental health institute beds
per capita than most other states.
Iowa is 47th in the nation with regard to psychiatrists per capita, but Iowa has a robust
advanced nurse practitioner program and emerging telehealth system. In addition, the
governor has announced the establishment of three new psychiatric residency
programs in Iowa.
Some look at this information and conclude Iowa’s MHDS system is in crisis and failing
Iowans with mental illness or disabilities, their families, and their communities. Others
see this information as a reflection of a robust, thriving, and growing MHDS system. In
reality Iowa has a healthy and progressive public mental health and disability system
with some challenges that need to be addressed.
Challenges to the MHDS System
Need to Increase and Improve Service Capability and Capacity
Less than 1 percent of Iowans have a serious mental illness, severe intellectual
disability, or co-occurring substance use disorder and serious multiple complex needs.
These include, but are not limited to, individuals that can be aggressive, have a serious
mental illness and a serious substance use disorder, and/or a serious criminal offense.
11/15/2016 Page 13
Across the nation these individuals are often safely, appropriately, and successfully
served in intensive integrated service settings that have a combination of 24 hour,
seven day a week staffing supervision and guidance, and extensive professional
treatment and oversight. Iowa needs to increase the number of and statewide access
to effective and efficient services such as these.
At the direction of the legislature a workgroup was formed in 2014 to address the
intensive services needed for adults with serious mental illness to live successfully in
the community. No substantive changes resulted from the report. The top five
recommendations from the 2014 report include:
1. High intensity, flexible and responsive services should be available for those
individuals with the most complex needs.
2. Housing assistance should be made available to support individuals with serious
mental illness in integrated housing.
3. Mental health services should be easily accessible and the system should be
easy to navigate.
4. Authorization and reimbursement for services should be person-centered, based
on best practices and outcomes, and should reasonably meet provider costs of
doing business.
5. Providers should have the capacity to meet the co-occurring and multi-occurring
needs of individuals with serious mental illness.
The 2014 report also found that non-clinical social services that are not identified as
core or core plus services are needed such as supported housing, financial assistance
for safe, decent, affordable housing, comprehensive peer support, and non-Medicaid
funded transportation. Since the report was issued it has become clear that increased
capacity is needed across the entire array of MHDS services to successfully serve
individuals with the most severe and multiple complex needs.
Many service providers lack the capacity to successfully and effectively serve Iowans
with the most serious service needs. Too many individuals are discharged from
community placement when their needs exceed the providers’ capability. These
individuals are far too often admitted to in-patient psychiatric hospitals and, when they
are ready to be discharged, have nowhere to go because of a lack of community-based
providers with the capacity to successfully serve them.
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At least 10 percent of all in-patient psychiatric hospital beds are vacant every day.
However these inpatient psychiatric hospital programs often do not accept patients, not
because there is a lack of beds, but because the hospital believes the individuals are
too difficult for them to serve. Some demand the development of more state or publicly
operated psychiatric hospital beds with longer lengths of stay. This would mean
community hospital beds would remain vacant and individuals would be placed in the
most restrictive, most expensive service option when they could be effectively served in
a more modern, effective, and efficient service.
MHDS Regions are not required to address the needs of individuals with severe multiple
complex needs. While some MHDS Regions have voluntarily expanded into “core plus”
services, such as comprehensive crisis services and jail diversion, others have not.
Failure to require all MHDS Regions to provide these services has created a new
inequity in services across the state. MCO funding has not yet been secured for crisis
services to help ensure the fiscal viability of these programs.
Alternative sub-acute services have been slow to develop. Smaller, more integrated 24
hour “habilitation homes” are slow to replace large residential care facilities that cannot
be funded by Medicaid and are being less frequently funded by MHDS Regions.
Example John is 48 years old and has an intellectual disability and autism. He lives with 3 roommates and is on the intellectual disability waiver. He has been physically and verbally aggressive to staff and roommates resulting in his arrest. John has been admitted to the hospital for inpatient psychiatric services multiple times. When he was last admitted to the hospital his waiver provider discharged him from services. This is the third waiver provider who has discharged him due to his behaviors. John has now been in the hospital for 4 weeks and is stable and ready for discharge, but has no where to go. Before these recent episodes John has proven he could live successfully with intensive home and community based services provided by well trained and supported providers that follow John’s behavior plan designed by a Board Certified Behavior Analyst.
Example Ann is 30 years old diagnosed with bi-polar disorder and substance use disorder. Her recent behavior has been erratic and unpredictable. Inpatient psychiatric services are being sought for her due to her hurting herself. Recently, she has had a history of multiple hospitalizations with long lengths of stay, aggression towards hospital staff and property, failure to comply with medication and other treatments. She has also been evicted from her apartment. Ann was taken to a local rural emergency department by the sheriff. The emergency department has not been able to find a community inpatient psychiatric hospital admission even by calling hospitals that show bed availability in the psychiatric hospital bed tracking system. Several years ago, before she was allowed to become non-compliant with her treatment, Ann was living successfully in a small home she shared with others while receiving 24 hour 7 day a week habilitation services and care coordination from an integrated health home. It is believed she could be successful again if she could have a brief stay in a hospital to stabilze, good discharge planning, and intensive habilitation and other mental health services.
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Each individual MCO is required to have a provider network sufficient to achieve
measurable outcomes of service access and community integrated service delivery.
However, the MCOs are not required to work jointly in developing a needed statewide
service capacity to meet the needs of individuals with the most severe, complex and co-
occurring needs.
An effort is needed to require both the MCOs and the MHDS Regions to collaborate to
develop intensive service options across the state to more effectively and efficiently
serve the less than 1 percent of Iowans with mental illness or disabilities or co-occurring
substance use disorder and severe multiple complex needs.
Substance use disorder (SUD) treatment is not closely connected with the MHDS
Region service systems. So, while at least 35 percent of all individuals with a serious
mental illness have co-occurring substance use disorder, there is no formal required
coordination of these service delivery systems. In addition, we are faced with an
emerging opioid epidemic that requires a coordinated response by many different
government entities at all levels. Therefore, the Department must collaborate with the
Iowa Department of Public Health to include SUD treatment as part of this coordination
effort.
Management structure
While successful in many ways, the MHDS Regions operate autonomously and do not
coordinate in providing a comprehensive statewide approach. MHDS Regions are
making efforts to work more closely together and with the Department. Consensus is
emerging from these efforts such as the need for comprehensive crisis services, jail
diversion services, sub-acute services, and developing capacity to serve individuals that
have difficult complex needs. However, the Department has not been given
responsibility and authority to work with MHDS Regions to manage and operate a
statewide MHDS system.
Both the MHDS Regions and MCOs face similar challenges to adequately serve broad
population groups effectively and efficiently. However, each of these separately
managed entities are developing, providing, and funding these efforts in each of their
own unique ways. In addition, MHDS Regions are locally managed and inwardly
focused and serve far fewer non-Medicaid funded services than in the past. MHDS
Regions have not established a role for themselves in Medicaid funded services.
Both the MHDS Regions and the MCOs are working voluntarily with the Department to
collaborate on initiatives such as braided funding for crisis services, uniform quality of
life outcome measures, and coordinated approaches to better serving individuals with
difficult, complex needs. However, these efforts are singular and isolated. Each of the
11/15/2016 Page 16
MHDS Regions and MCOs operates autonomously. Nothing requires the MHDS
Regions or the MCOs to operate cooperatively and collaboratively on statewide goals
and outcomes. The individual parts of these public MHDS systems do not operate as a
coordinated system of service delivery that is easily understood and used by Iowans
that need them. The Department needs responsibility and authority to require the both
MCOs and the MHDS Regions to collaborate to develop and operate a unified system
of MHDS service delivery.
Finally, since the MHDS Regions are only required to manage services for adults, no
semblance of a children’s system exists.
Workforce Challenges
Iowa has a serious MHDS workforce shortage and does not have a comprehensive plan
to address it. Iowa ranks 47th in the nation in the per capita number of psychiatrists.
Limits exist for what trained mid-level practitioners can do, especially in hospitals. In
addition the governor has announced the establishment of three new psychiatric
residency programs in Iowa. Similar challenges are faced with behavioral health and
disability professionals. Direct care professionals are difficult to find, turnover is high,
and adequate training is insufficient. Additionally, Iowa has very few training sites for
Board Certified Behavior Analysts.
Recommendations
To strengthen the effectiveness and efficiency of the MHDS Regions, the Department
recommends the following:
MHDS Regions should: have a minimum number of county residents in each
region, pool county funding, and maintain continuity in their leadership.
MHDS Regions and MCOs should identify funding for the provision of all Core
and Core Plus services to individuals with a mental illness or an intellectual
disability.
MHDS Regions should continue building the community service system by
planning for the provision of critical, non-clinical social services, such as, but not
limited to, housing and transportation.
The MHDS Regions’ responsibility and authority for effectively and efficiently
serving individuals that are the most difficult to serve should be clarified.
To address the most pressing statewide MHDS system and behavioral health need (i.e.,
a complete and effective array of supports, treatment and care for individuals that are
the most difficult to serve) the Department will:
11/15/2016 Page 17
Immediately convene a workgroup that includes MHDS Regions, MCOs, and
other key stakeholders to identify effective services for individuals with severe multiple complex needs and report recommendations for the provision of those identified services.
11/15/2016 Page 18
Appendix A:
HF 2460 DIVISION XIX MENTAL HEALTH AND DISABILITY SERVICES REDESIGN PROGRESS REPORT Sec. 89 MENTAL HEALTH AND
DISABILITY SERVICES REDESIGN PROGRESS REPORT
The Department of Human Services shall review and report progress on the implementation of the adult mental health and disability services redesign and shall identify any challenges faced in achieving the goals of the redesign. The progress report shall include but not be limited to information regarding the mental health and disability services regional service system including governance, management, and administration; the implementation of best practices including evidence-based best practices; the availability of, access to, and provision of initial core services and additional core services to and for required core service populations and additional core service populations; and the financial stability and fiscal viability of the redesign. The department shall submit its report with findings to the governor and the general assembly no later than November 15, 2016.
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Appendix B: MHDS Region Map
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Appendix C: Population Per MHDS Region
Region
2015
Population
Estimate
Number of
Counties in
the Region
MHDS of the East Central Region (MHDS-ECR) 587,004 9
Polk County Health Services 467,711 1
County Social Services (CSS) 462,447 22
Central Iowa Community Services 326,018 10
Eastern Iowa MHDS Region 300,689 5
Southwest Iowa MHDS Region 189,780 9
Southeast Iowa Link (SEIL) 163,588 8
Sioux Rivers MHDS 162,519 3
Heart of Iowa Region 105,609 4
Rolling Hills Community Services Region 96,526 7
County Rural Offices of Social Services, CROSS 78,881 7
South Central Behavioral Health Region 78,795 4
Northwest Iowa Care Connection 74,634 6
Southern Hills Regional Mental Health 29,698 4
Statewide Totals 3,123,899 99
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Appendix D: Core Service Access Standards
Service Domain Core Services Included Access Standard
Domain: Treatment (Outpatient)
Assessment & evaluation
Mental health therapy
Medication prescribing
Medication management
Emergency: during an emergency, outpatient services shall be initiated to an individual within 15 minutes of telephone contact
Urgent: outpatient services shall be provided to an individual within one hour of presentation or 24 hours of telephone contact
Routine: outpatient services shall be provided to an individual within 4 weeks of request for appointment
Domain: Treatment (Inpatient) Inpatient mental health Emergency: an individual in need of emergency inpatient services shall receive treatment within 24 hours
Proximity: Inpatient services shall be within a reasonably close proximity to the region (100 miles)
Assessment and evaluation after an individual has received inpatient services
Timeliness: an individual who has received inpatient services shall be assessed and evaluated within 4 weeks.
Domain: Basic Crisis Response 24 hour access to crisis response
Personal emergency response system
Timeliness: Access to crisis series, 24 hours a day, seven days a week, 365 days per year
Crisis evaluation
Timeliness: Crisis evaluation with 24 hours
Domain: Support for Community Living
Home health aide
Respite
Home and vehicle modification
Supported community living
Timeliness: The first unit of service shall occur within 4 weeks of the individual’s request of service.
Domain: Support for Employment Prevocational services
Day habilitation
Job development
Supported employment
Timeliness: The first unit of service shall occur within 4 weeks of the individual’s request of service.
Domain: Recovery Services Family Support
Peer Support
Proximity: An individual receiving recovery services shall not have to travel more than 30 miles if residing in an urban area or 45 miles if residing in a rural area to receive services.
Domain: Service Coordination Case management
Health homes
Timeliness: An individual shall receive service coordination within 10 days of the initial request or
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Service Domain Core Services Included Access Standard
being discharged from an inpatient facility
Proximity: An individual receiving service coordination shall not have to travel more than 30 miles if residing in an urban area or 45 miles if residing in rural area to receive services
Dashboard Showing MHDS Regions Meeting Core Service Standards – September 30, 2016
Region
TREATMENT: Outpatient TREATMENT: Inpatient
Timeliness Emergency
Timeliness Urgent
Timeliness Routine
Proximity Timeliness Emergency
Timeliness Assessment/ Evaluation
Proximity
Central Iowa Community Services
Met Met Met Met Met Met Met
County Rural Offices of Social Services
Met Met Met Met Met Met Met
County Social Services Met Met Met Met Met Met Met
Eastern Iowa MHDS Region Met Met Met Met Met Met Met
Heart of Iowa Region Met Met Met Met Met Met Met
MHDS of East Central Region
Met Met Unmet Met Met Met Met
Northwest Iowa Care Connections
Unmet Met Met Met Met Met Met
Polk County Health Services Met Met Met Met Met Met Met
Rolling Hills Community Services Region
Met Met Met Met Met Met Met
Sioux Rivers MHDS Met Met Met Met Met Met Met
South Central Behavioral Health Region
Met Met Met Met Met Met Met
Southeast Iowa Link Met Met Met Met Unmet Met Unmet
Southern Hills Regional Mental Health
Met Met Met Met Met Met Unmet
Southwest Iowa MHDS Region
Met Met Met Met Met Met Met
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Region
BASIC CRISIS RESPONSE
SUPPORT FOR
COMMUNITY LIVING
SUPPORT FOR EMPLOYMENT
RECOVERY SERVICES
SERVICE COORDINATION
Timeliness 24 Hour Access
Timeliness Assessment/Evaluation
Timeliness Timeliness Proximity Timeliness
Routine Proximity
Central Iowa Community Services
Met Met Met Met Met Met Met
County Rural Offices of Social Services
Met Met Met Met Met Met Met
County Social Services Unmet Unmet Met Met Unmet Met Met
Eastern Iowa MHDS Region
Met Met Met Met Unmet Met Met
Heart of Iowa Region Met Met Met Met Unmet Met Met
MHDS of East Central Region
Met Met Met Met Met Met Met
Northwest Iowa Care Connections
Met Unmet Met Met Met Met Met
Polk County Health Services
Met Met Met Met Met Met Met
Rolling Hills Community Services Region
Met Met Met Met Met Met Met
Sioux Rivers MHDS Met Met Met Met Met Met Met
South Central Behavioral Health Region
Met Met Met Met Met Met Met
Southeast Iowa Link Unmet Met Met Met Met Met Met
Southern Hills Regional Mental Health
Met Met Met Met Met Met Met
Southwest Iowa MHDS Region
Met Met Met Met Unmet Met Met
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Appendix E:
Core Plus Services – 9/30/16
MHDS Region
24Hour Crisis Line
Mobile Response
23 Hour Crisis
Observation & Holding
Crisis Stabilization/Community
Crisis Stabilization/
Facility
Sub Acute
Jail Diversion
Crisis Intervention
Training
Civil Commitment
Prescreen
Central Iowa Community Services
X X X X X X
County Rural Offices of Social Service
X X X
County Social Services
X X X X X X
Eastern Iowa MHDS Region
X X X
Heart of Iowa Region
X X X X
MHDS of East Central Iowa Region
X X X X
Northwest Iowa Care Connection
X X
Polk County Health Services
X X X X X
Rolling Hills Community Services
X X X X
Sioux Rivers MHDS
X X X X X
South Central Behavioral Health
X X X X
Southeast Iowa Link
X X X
Southern Hills Behavioral Health
X
Southwest Iowa MHDS
X X X X X X
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Appendix F: Evidence Based Practices
EBPs have the following characteristics:
• Transparency: Both the criteria and the process of review are subject to peer-
review.
• Research: Accumulated scientific evidence based on randomized controlled
trials.
• Standardization: The practice’s essential elements are clearly defined.
• Replication: More than one study and group of researchers have found positive
effects.
• Fidelity Scale: A valid, reliable fidelity scale is used to verify that an intervention
is being implemented in a manner consistent with the treatment model.
• Meaningful Outcomes: Consumers are shown to achieve meaningful outcomes.
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Appendix G: Summary of Maximum County MHDS Levies
PER CAPITA AMOUNT BASED ON MAXIMUM MHDS LEVY
Region County 2015 Pop Estimate
2018 Max Levy Per Capita
Central Iowa Community Services Boone 26,643 878,976 32.99
Franklin 10,295 358,934 34.86
Hamilton 15,190 718,183 47.28
Hardin 17,367 821,112 47.28
Jasper 36,827 1,741,181 47.28
Madison 15,753 534,189 33.91
Marshall 40,746 1,926,471 47.28
Poweshiek 18,550 444,227 23.95
Story 96,021 3,066,575 31.94
Warren 48,626 1,084,011 22.29
326,018 11,573,859 35.50
County Rural Offices of Social Services Decatur 8,220 321,858 39.16
(CROSS) Clarke 9,259 430,559 46.50
Lucas 8,682 410,485 47.28
Marion 33,294 1,089,896 32.74
Monroe 7,973 340,278 42.68
Ringgold 5,068 239,615 47.28
Wayne 6,385 254,099 39.80
78,881 3,086,790 39.13
County Social Services (CSS) Allamakee 13,886 656,530 47.28
Black Hawk 133,455 5,779,837 43.31
Butler 14,915 389,899 26.14
Cerro Gordo 43,017 2,033,844 47.28
Chickasaw 12,097 571,946 47.28
Clayton 17,644 834,208 47.28
Emmet 9,769 461,878 47.28
Fayette 20,257 773,024 38.16
Floyd 15,960 610,064 38.22
Grundy 12,435 530,188 42.64
Hancock 10,974 518,851 47.28
Howard 9,410 364,201 38.70
Humboldt 9,555 451,760 47.28
Kossuth 15,165 717,001 47.28
Mitchell 10,832 512,137 47.28
Pocahontas 7,008 331,338 47.28
Tama 17,337 568,799 32.81
Webster 37,071 1,752,717 47.28
Winnebago 10,609 433,910 40.90
Winneshiek 20,709 979,122 47.28
Worth 7,569 357,862 47.28
Wright 12,773 554,967 43.45
462,447 20,184,083 43.65
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Eastern Iowa MHDS Region Cedar 18,340 867,115 47.28
Clinton 47,768 2,258,471 47.28
Jackson 19,444 787,145 40.48
Muscatine 43,011 2,033,560 47.28
Scott 172,126 3,308,032 19.22
300,689 9,254,323 30.78
Heart of Iowa Region Audubon 5,773 272,947 47.28
Dallas 80,133 1,524,538 19.03
Greene 9,027 426,797 47.28
Guthrie 10,676 504,761 47.28
105,609 2,729,043 25.84
MHDS of the East Central Region Benton 25,658 908,642 35.41
(MHDS-ECR) Bremer 24,722 1,168,856 47.28
Buchanan 21,062 995,811 47.28
Delaware 17,403 822,814 47.28
Dubuque 97,125 4,592,070 47.28
Iowa 16,401 729,235 44.46
Johnson 144,251 3,138,395 21.76
Jones 20,466 883,021 43.15
Linn 219,916 8,195,141 37.26
587,004 21,433,985 36.51
Northwest Iowa Care Connection Clay 16,507 402,866 24.41
Dickinson 17,111 412,509 24.11
Lyon 11,745 248,113 21.12
Obrien 13,984 570,532 40.80
Osceola 6,154 195,225 31.72
Palo Alto 9,133 431,808 47.28
74,634 2,261,053 30.30
Polk County Health Services Polk 467,711 14,439,175 30.87
Rolling Hills Community Services Region Buena Vista 20,493 669,512 32.67
Calhoun 9,818 431,560 43.96
Carroll 20,498 969,145 47.28
Cherokee 11,574 477,158 41.23
Crawford 17,094 808,204 47.28
Ida 7,028 300,889 42.81
Sac 10,021 473,793 47.28
96,526 4.130,261 42.79
Sioux Rivers MHDS Plymouth 24,800 363,771 14.67
Sioux 34,937 1,027,388 29.41
Woodbury 102,782 3,564,086 34.68
162,519 4,955,245 30.49
South Central Behavioral Health Region Appanoose 12,529 592,371 47.28
Davis 8,769 414,598 47.28
Mahaska 22,324 1,055,479 47.28
Wapello 35,173 1,662,979 47.28
78,795 3,725,427 47.28
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Southeast Iowa Link (SEIL) Des Moines 40,055 1,751,030 43.72
Henry 19,950 846,381 42.43
Jefferson 17,555 607,300 34.59
Keokuk 10,163 480,507 47.28
Lee 35,089 1,659,008 47.28
Louisa 11,185 528,827 47.28
Van Buren 7,344 314,328 42.80
Washington 22,247 781,141 35.11
163,588 6,968,522 42.60
Southern Hills Regional Mental Health Adair 7,228 309,066 42.76
Adams 3,796 179,475 47.28
Taylor 6,205 140,346 22.62
Union 12,469 589,534 47.28
29,698 1,218,421 41.03
Southwest Iowa MHDS Region Cass 13,427 634,829 47.28
Fremont 6,906 326,516 47.28
Harrison 14,265 674,449 47.28
Mills 14,844 609,781 41.08
Monona 8,979 375,993 41.87
Montgomery 10,234 369,740 36.13
Page 15,527 652,027 41.99
Pottawattamie 93,671 4,428,765 47.28
Shelby 11,927 563,909 47.28
189,780 8,636,009 45.51
Statewide Totals
3,123,899 114,596,196 36.68
